How to succeed at eye drop treatment: It’s all in your hands

Face the ceiling when putting drops in. Maybe teenagers can look in a mirror, tilt their head way back and get a drop in the eye, but for most of us, several drops wind up on the floor that way. Get horizontal when taking drops, tilt your head way back while sitting in a big comfy chair or better, lie flat in bed.

Brace the back of the hand with the bottle on your forehead before tipping it up. We all have tremors and having the bottle waving around without support hurts your aim.

Next, before you tilt the bottle over, look up to see that the tip is over the nose half of your eye. Since you’re going to be looking through the top of your head (see below) when the drop falls, you can’t (and don’t want to) see it falling anyway. If any of the drop falls on the area on the nose side of the eye, even if some hits the edge of the eyelid or the inner corner, enough will get on the eye surface to do the job. If you miss on the temple side, it’s likely to treat the glaucoma in your ear, not your eye.

Pull down the lower eyelid of the eye with the hand that isn’t holding the bottle. This increases the target on the white part of the eye. As soon as the drop hits the eye, you can let go.

Let the bottle deliver as you tip it over and only squeeze if it doesn’t come out by itself. This means that you will tip the bottle over, above the nose side of the eye, and let it fall by gravity from about 2 inches or less. Some bottles start having drops come out right away. If the drop doesn’t come out by itself, squeeze gently until it does.

Use only one drop per eye! Yes, we know that some bottles say put in 2 drops (so does the information sheet from some drug stores). That’s a huge waste. Each drop (which has from 25-50 microliters of fluid) contains probably 5 times more drug than is needed for each treatment. So even if you have 80% of it go somewhere else than on the eye surface, you’re OK. The drop is absorbed mostly through the clear part of the eye, the cornea. Furthermore, using two drops gives you a greater chance for bad effects on the rest of the body. When you put medicine on the eye, it mixes with the tears, and this drains into the nose through the lacrimal (tear) system in the corner of the eye near the nose. That’s why you sometimes taste drops in your nose and throat when you take them. It’s also why cocaine abusers snort drug up their nose—it’s an effective method to get drugs into the body and head. The same goes for eye drops, but with drops you want the least amount anywhere else other than on the front of the eye.

As soon as you hit the eye with a drop, close the eyelids and don’t blink for 60 seconds. We’re now onto some pretty thin ice, scientifically. There is some evidence that not blinking leaves the drop on the eye longer—thus making it go into the eye more. But, when we tested the actual pressure lowering with and without the don’t blink instruction, it didn’t make a substantial difference. So it makes sense not to blink, but we can’t say it has definitive support.

Many doctors teach patients to push on the inner nose for 1 minute after putting the drop on the eye, to block the lacrimal drain area and keep drops out of the nose, throat and the rest of the body. Certainly, this naso-lacrimal occlusion makes logical sense, and there is evidence that for children this can reduce the level of drug that can be found in the blood stream after drops—which is a really good idea if you are someone sensitive to the general body effects of whichever drop you are using. However, very few patients are doing nasolacrimal occlusion correctly when we ask them to show us where they are pushing. The fingers must be far back from the bridge of the nose (almost poking the eye) and pushing almost hard enough to hurt in order to stop drug from going to the nose.

After the drop hits and you close your eyes, some will be on the skin of the eyelids. Blot off the excess, since some of us are sensitive to it or may have an actual allergy to the drug or its component parts. We don’t want to expose the skin daily to something that may lead to itching, redness, and puffy lids. This requires having facial tissues around before you start putting in drops.

You can treat one eye at a time, close, blot, push the nose, and then treat the other eye in the same way. Or, if you’re a veteran and can hit both eyes pretty quickly, you can do drop right, drop left and close both, blot both, and push on both sides of the inner nose with the thumb and forefinger for the 60 seconds. If you need to take more than one kind of drop at that time of day, it’s faster to do both eyes at once.

Wait between two types of drop on the same eye. Many glaucoma patients need to use more than one drug to keep pressure at target. They may have two or three bottles to put in, morning and evening. If you put in drop 1 and in less than 60 seconds you put in drop 2, the second one will wash away the first one and you’re not getting the full effect of either one. Now the controversy: how long to wait between bottles? We’ve heard doctors tell patients to wait 15 minutes! This would mean that the person with 3 kinds of drops would need nearly an hour to get the medicine in. There are no conclusive studies of how long to wait. We suggest that the shortest possible time should be 2 minutes, and if you have a system that lets you wait 5 minutes it’s possibly better. However, humans being humans, we know that if you put in drop 1, then say—"I’ll just dry the dishes and come back for the second drop," you’re more likely than not to forget to come back. Don’t walk away until they’re all in.

If you’re using more than one type of drop, the order in which they go in doesn’t matter. At least something is easy.

Running out of medicine can be a big cause of non-adherence. Many pharmacy plans give you either a 1 month or a 3 month supply of drug. They don’t usually give you more than you need and typically it is just barely enough if you use one drop at a time. The biggest cause of running out of drug is using too much each time. Use one drop if possible! A second cause for running out is not planning ahead. If you’re going to the beach, you won’t forget the beach chairs, but an astonishing number of people leave their eye drops at home. Most doctors can fill a new bottle at the ocean-side drug store, but you’ll probably pay full price for it. There is a third rule of drops, namely, they always run out late on Friday night after the doctor’s office is closed. Give things a shake on Thursday and see if you’re going to need more. Fourth, the Food and Drug Administration (FDA) puts an “expiration date” on drop bottles. This is something to look for when the druggist gives you a 3 month supply—make sure they won’t already have expired before the 3 months is up. Finally, a very disturbing (but understandable) finding in one research project was that needing to use a second eye drop type every day led some patients to delay refilling the first bottle until they needed to get both bottles filled. Some drops come as combinations of two types in one bottle and this may help you with this problem.